Response to “Seroma Prevention in Abdominoplasty: Eliminating the Cause”

First, I would like to express my great admiration to Dr Swanson for providing a valuable example for the exercise of the scientific method. It is inevitable that his observations, accumulated from extensive experience, have generated a hypothesis to be tested and verified. The hypothesis that seroma is caused by thermal injury is by no means a new concept, and has been advocated by some authors in the past. There may have been some merit to the hypothesis in the times where electrosurgery was rudimentary and old diatherms were true candles flaming the surrounding tissue. The power efficiency rating (PER) is a measure of the ability of an electrosurgical generator to accurately deliver the selected power into a wide range of tissue types. Newer models can achieve PER 98 out of 100, while older devices can reach only around 60. Moreover, the addition of modern coated scalpels to an updated electrosurgery device enables us to minimize thermal injury. We used electrosurgery in all our patients (Valleylab by Covdien, Minneapolis, MN, USA) and I apologize for not clarifying this point in greater detail in my previous paper. When we review the current literature, we find an average of 2–15% seroma in the majority of recent papers. Pitanguy published his abdominoplasty results in 1975 with 5.8% seroma rates using scalpel dissection. This paper, which describes a technique 30 years older than Dr. Swanson’s letter, produced very similar results as his. Hester et al presented 2.5% seroma rates using electrodissection, and the same low rate is accomplished by many other surgeons. This alone should run counter to Swanson’s postulation that the dissection with a cold blade leads to less seroma. We respectfully concede to Dr. Swanson’s statement that a 5% seroma rate is a tolerable nuisance for patients and surgeons. Nevertheless, abolishing this nuisance, as we demonstrated in our paper, seems much more tolerable. We are consistently led to believe that plastic surgeons are a very special group of individuals, with a wide array of peculiarities pertinent to our speciality, amongst which fear of technology seems to be highly expressed. I doubt that one of our neurosurgeon colleagues would find not having a gamma knife acceptable, while a cardiologist would not propose surgery before an endovascular procedure or an ophthalmologist would not perform a cataract surgery without phacoemulsification. Meanwhile, we use obsolete breast implants without any upgrades for 20 years, we do not embrace new suturing materials/techniques, we are not allowed to use stem cells in our practices (when the rest of the world is so much ahead of us), and ultimately some propose that abolishing technology is the solution to abdominoplasty’s seromas. Therefore, I believe that the extent to which such issues can be embedded in our long-lasting debates is more profound. I believe that the challenge that I face every day in my office is how to adapt my “old ways” to my “newways” for patients to have better and safer treatments. I concur, as many other scientists do, that science and technology are bound to function together. So, let’s use our sword skills to force the industry to bring advances to our speciality, like a true Zorro!